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Achievements in the 6th National Conference of Infusion Nurses Society India 2017

The Sixth National Conference of INS India was conducted on 11th and 12th August 2017 with the theme - Achieve Excellence with Infusion Standards - at Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai with various oral and poster presentation in different categories. Three delegates representing Amrita Institute of Medical Sciences along with the Nursing Director (GC Member- INS India) participated in the conference. The achievements were:

Ms. Radhika Mohandas bagged First position for the Oral Paper Presentation onIMPACT OF IV TEAM IN OUR ORGANISATION.

Mr. Visakh V. bagged Second position for the Poster on Paediatric Infiltration; A march to best outcome through best practice.

Ms. Sowmya M. N. secured First position in Scientific Paper Presentation on Impact of RN turnover on Incidences of Peripheral IV Complications in a Tertiary Care Hospital.

INS Master Mind Final Quiz National Level Competition was conducted on 11th August 2017 with 5 teams representing North, East, West, South 1 and South 2. Ms. Sowmya M. N. (Amrita Hospital, Kochi) and Ms. Jisha John (Rajagiri Hospital, Kochi) were selected as ‘the South 2 team’ among 900 RNs and bagged First position for the INS Master Mind Final Quiz National Level Competition.

Dr. Bhaskaran Pillai honoured by American Association of Physicists in Medicine

Prof. (Dr.) Bhaskaran Pillai, Professor and Head, Medical Physics & Radiation Safety, Amrita Institute of Medical Sciences has been elected as Fellow of the American Association of Physicists in Medicine (AAPM). He was recently recognized as Fellow at the 59th Annual meeting of AAPM and their awards function at Denver, CO.

Prof. (Dr.) Bhaskaran K. Pillai worked as a Senior Scientific Officer heading the Division of Medical Physics at the Bhabha Atomic Research Centre India. He obtained a MS in Radiological Sciences at the University of Wisconsin, and a PhD in Biomedical Physics at the UT Health Science Center, San Antonio.

He is certified by the ABR in Therapeutic, Diagnostic and Medical Nuclear Physics. He was a member of several committees of AAPM and has several publications to his credit, including a book chapter; several abstracts and presentations at national and international conferences.

Dr. Pillai has been responsible to initiate Medical Physics and Radiation Safety department at Amrita. He has passionately formulated state-of-the-art Quality Assurance processes for all Radiation Oncology & Radiology modalities. He has trained and mentored 48 Medical Physicists. He also instituted a two-year Post Graduate Diploma Program in Medical Radiological Sciences, employing a distance learning internet tool where an all-volunteer faculty from the USA, Canada, and Australia interactively teach students in India.

Recurrent Ovarian Cancer treated Successfully with Robotic Surgery

Septuagenarians look forward to spending time with family and the fruits of retirement. However, it was not the case of a 74 year old. Being diagnosed with cancer at any age is worrisome and the memories of the treatment were not very pleasant one especially postoperatively along with chemotherapy in 2014. However, the fight was not over just yet for the patient as there was a recurrence of ovarian cancer that was detected during a follow up check up in 2017.

At age 77, chemotherapy was no longer an option and surgical removal of the tumor was the only option left. The patient was apprehensive and reluctant about the surgery given her previous experience, which was not a very encouraging. That’s when Dr Anupama R, Clinical Professor, Gynaecologic Oncology, Amrita Institute of Medical Sciences suggested robotic surgery. This case was discussed in the multidisciplinary tumor board and all doctors agreed that robotic surgery would be the best option for the patient. The affected area was completely removed using robotic assisted surgery, da Vinci Surgical System. This time around, the patient was discharged on the next day as the procedure was completely and hence pain free.

This is one of the many cases where Amrita Hospital has embraced modern technology, particularly the use of robot assisted surgery. Contrary to popular belief, the surgeon uses the robot as a tool to perform the surgery and it is not an automated process. The advantage of using robotic surgery is the short, sometimes unimaginable, recovery period is shorter than routine laparoscopic procedure. However, robotic technology with its better vision and small and precise instruments helps the surgeon perform complicated surgeries with minimum tissue damage since oncologic surgeries are more complex than routine gynaecologic surgeries. The use of robotic surgery translates into shorter hospital stay, lesser fatigue and faster recovery for the patient. Additionally, the duration of the surgery on an average is 1 to 2 hours.

In countries like the United States and UK, robotic surgery is being offered even for routine procedures and slowly even India is catching up. Robotic surgery was introduced at Amrita Hospital in January 2015. In the short span of two and a half years, Dr Anupama R has treated over 260 patients with gynaecological cancer and other gynaecological problems with the help of robotic surgery.

The main theme of the seminar was “Pathology of Female Genital Tract.” Many international and national experts delivered lectures to over 200 delegates. According to the experts at the seminar, gynaecological cancers are the most common form of cancer in women with a high mortality and morbidity hence it is an important public health issue. However with the advances in medical science, early detection facilities along with customised patient care and cure are now available. The seminar comprehensively reviewed the latest cutting edge diagnostic and therapeutic modalities.

The department of Radiation Oncology at Amrita Institute of Medical Sciences, Kochi recently conducted Amrita Annual High Precision Radiation Therapy Workshop and CME over the course of three days on 30th June, 1st and 2nd July 2017. The workshop focused on imparting hands on training on the use of CyberKnife. The academic session included a live demonstration on the treatment of liver tumors. Liver tumors are very common in Kerala and it is difficult to treat using traditional methods in certain cases. However, radiosurgery serves as a treatment option for these patients. Additionally, the experts taking these sessions represented top hospitals across the country including Tata Memorial Hospital, Fortis Hospital and Apollo Hospital just to name a few.

CyberKnife is an option in Inoperable and Recurrent Liver Cancer: Dr Debnarayan Dutta

Hepatocellular carcinoma is a cancer of the liver cells. It is usually associated hepatitis infections, toxins (hepato-toxins), many chemicals we use daily, alcohol and also with substance abuse. As per the ICMR data, incidence of hepatocellular carcinoma ranges from 0.7 to 7.5 per 100,000 in the Indian population. Liver cancer is a problem in Kerala; there is an assumption that the incidence is higher than the national average.

Majority of these primary liver cancers (hepatocellular carcinoma) are treated with surgery, trans-arterial chemo embolization (TACE) and radiofrequency ablation (RFA). But, as majority the of these patients are presented with advanced disease since recurrence is common. Many patients have blockade in the portal vein (portal vein thrombosis), and they have only few treatment options available. These patients are usually on palliative chemotherapy with dismal prognosis. Many of these patients have preserved functional status (good general condition), and there is a dilemma regarding their management. There is a need to explore newer treatment options in these 'difficult to treat' patients. Sometimes, surgery is also difficult in patients with small lesions close to porta hepatis (blood vessels) and subdiaphramatic (below the diaphragm - subdiaphramatic location) location. These patients usually don't have any suitable treatment option and are treated with chemotherapy.

Primary liver cancer is relatively chemotherapy and radio-resistant. Higher doses of radiation or specific chemotherapy are required to have any significant clinical benefit. There is a technical challenge in delivering high dose to the liver tumour and sparing other parts of normal liver. Hence, radiation therapy was never considered as a viable option in liver tumours, till recently. We have recently found a technique to deliver high dose of radiation to the tumour safely. The liver is sensitive to radiation therapy, and tolerance is low. It means that even a low dose of radiation on the whole liver will cause 'radiation induced liver injury'. Normal radiation therapy with high 'scattering' of dose leads to high 'mean' dose to liver. Therefore, it is difficult to deliver high dose with standard radiation equipment. Liver moves with respiration, hence we need to treat a larger area with standard radiation equipment, and hence higher dose to liver is delivered.

Primary liver tumour (Hepatocellular carcinoma, cholangiocarcinoma) need a higher dose of radiation needs to be delivered, which not possible with standard radiation machines. With available radiation machines deliver higher dose to normal liver and less than appropriate dose to the tumour. A high dose to liver is associated with toxicity and lower dose to tumour with response to treatment. Hence, with standard radiation therapy techniques there are higher side effects and lower response to treatment. Radiation therapy was never considered an option previously as an option even in inoperable or recurrent disease. There are only few systemic therapy options in hepatocellular carcinoma (Sorafinib) and the outcome is par below the expectations.

Radiosurgery is a precise radiation therapy delivery technique to deliver high dose radiation to the target while sparing the adjacent critical structures. Robotic radiosurgery (CyberKnife) is a robot assisted 'real time' image guided radiation therapy delivery technique where high dose short course radiation therapy is delivered to the target sparing adjacent normal liver.

High-resolution contrast CT scan and MRI scan helps to locate the tumour accurately, computer assisted contouring and planning system helps to plan the treatment precisely. CyberKnife treatment does not need any margin, as there is real time tracking and the robot 'chase' the tumour during respiratory motion. Gold seeds called 'fiducials' are placed near the tumour and the machine has the capability to track the 'fiducials' during real time imaging and treatment. Hence, high dose radiation therapy is delivered precisely with robotic arm based linear accelerator to the moving target with real time tracking and real time imaging. Accuracy of treatment is very high (within 1 mm) and monitored by computer-assisted systems.

Higher dose to the target and sparing of normal liver has enabled physicians to deliver high dose radiation to the target, which has translated to better local control with lesser side-effects. Usually, 45 Gy of radiation dose is delivered to the target in three days as out-patient procedure. As a policy, 800 cc of normal liver is saved to function properly. Usual liver volume is around 1200 to 1500 cc. There is no major toxicities during treatment and a large proportion of patients respond to treatment at 2 to 3 months follow up evaluation.

CyberKnife robotic radiosurgery is considered the most appropriate treatment option for fiducial guided liver cancer treatment. CyberKnife is an option in otherwise inoperable situations, such as tumour close to porta or subdiaphramatic location or multiple lesions in different lobes of liver. Radiosurgery with CyberKnife is now considered a standard option in inoperable, recurrent/ progressive liver tumours. There are many prospective randomized trials being conducted world over to find if CyberKnife can be an option even in smaller lesions as a non-invasive option even in operable liver cancers. Early studies with smaller lesion have shown that CyberKnife is equally effective as surgery with lesser side effects.

There is a need to increase awareness regarding the liver cancer treatment options, especially in inoperable or 'difficult to do surgery' patients those are relatively young (less than 60 years) and have preserved function status (good general condition).